Provider Demographics
NPI:1437296613
Name:IKEFUGI, TAE KIM (OD)
Entity Type:Individual
Prefix:DR
First Name:TAE
Middle Name:KIM
Last Name:IKEFUGI
Suffix:
Gender:F
Credentials:OD
Other - Prefix:DR
Other - First Name:AMY
Other - Middle Name:TAE
Other - Last Name:KIM
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:OD
Mailing Address - Street 1:21880 HAWTHORNE BLVD STE 340
Mailing Address - Street 2:
Mailing Address - City:TORRANCE
Mailing Address - State:CA
Mailing Address - Zip Code:90503-7035
Mailing Address - Country:US
Mailing Address - Phone:310-542-7070
Mailing Address - Fax:310-542-7070
Practice Address - Street 1:21880 HAWTHORNE BLVD STE 340
Practice Address - Street 2:
Practice Address - City:TORRANCE
Practice Address - State:CA
Practice Address - Zip Code:90503-7035
Practice Address - Country:US
Practice Address - Phone:310-542-7070
Practice Address - Fax:310-542-7070
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-30
Last Update Date:2010-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA11897T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CASD0118970Medicaid
CASD0118970Medicaid
CA11897TMedicare ID - Type Unspecified